Acknowledgements
This research was made possible through the support of the
Bureau for Population, Refugees and Migration at the U.S.
Department of State. The authors would like to express their
deepest gratitude to all those who participated and facilitated
research for the project. Special thanks to Saint Lukeâ&#x20AC;&#x2122;s
Association Clinic for their time and efforts to accommodate
the research team and for providing the photograph on
the cover of the report. The authors would also like to
acknowledge project officer Sarah Cross for her tireless work.

Introduction
Mainstreaming of refugees into host country health,
education and social service programs presents unique
challenges in urban areas. Even when governments
are open to such mainstreaming, refugees experience
numerous barriers to utilization of mainstream programs
while host communities find that often limited resources
are stretched thin while accommodating a new population
in need of services. To respond to these challenges, the
UN High Commissioner for Refugees (UNHCR) adopted
policy guidelines in 2009 that set out new approaches
for addressing the needs of urban refugees. The
guidelines specified that if the goals were to be achieved:

financial resources) to host country medical specialists or,
in rare cases, to third countries for medical resettlement.
This report is based on field research that took place
between December 2010 and January 2012 that examined
the mainstreaming of Iraqi and other refugees in Amman
into the Jordanian health care system.1 Unlike many other
host countries, Jordan has explicitly encouraged refugees to
use its primary health care system while working with the
UNHCR to transition refugees from a nascent parallel system
of refugee-specific services that had been established soon
after Iraqi refugees arrived in Jordan in large numbers. That
Jordan has embarked on a policy of mainstreaming is all
the more noteworthy because Ministry of Health officials
repeatedly emphasize that Jordan is a country with limited
resources and believe that the health and education sectors
are already aggravated by the influx of newcomers. As
discussed in further detail below, the government has been
able to pursue health mainstreaming through collaboration
with the UNHCR and World Health Organization (WHO),
particularly in support of hospital-based services; its
openness to working with nongovernmental organizations
funded through UNHCR, which has allowed for the pooling
of health related resources; and generous support from the
United States to strengthen the mainstream health care
system. Without this continued support, the Government
of Jordan holds that it cannot be expected to provide
free and subsidized services for Iraqis or other refugees.

An appropriate resource base will be required, coupled
with effective cooperation and support from a wide
range of other actors, especially those host governments
and city authorities in the developing world that
so generously host the growing number of urban
refugees. In this respect, UNHCR encourages states to
respect and give practical meaning to the principle
of international solidarity and responsibility-sharing.
In 2011, UNHCR promulgated specific guidance
regarding the health services to refugees in urban areas,
recommending that refugees be mainstreamed into the
primary health care system of host countries to the fullest
extent possible. The health guidelines further recommended
referral of urban refugees with chronic diseases and
tertiary health problems (at least to the extent of available

Methodology
The methods consisted of interviews, focus groups, and
discussions with refugees and stakeholders that were
undertaken during three research trips in 2011 and 2012.
Stakeholders included Jordanian governmental officials
in the Ministry of Health and the Ministry of Planning and
representatives from local nongovernmental organizations
(NGOs) and community based organizations (CBOs),
international NGOs (INGOs), and international organizations
(IOs); IOs included representatives from UNHCR, International
Organization for Migration (IOM), World Health Organization,
and the UN Relief and Works Agency for Palestinian
Refugees (UNRWA). NGOs and INGOs that provide a range
of services to refugees, which were interviewed, included
Caritas, Jordan Health Aid Society (JHAS), International
Medical Corps (IMC), International Relief and Development
(IRD), CARE, and Center for Victims of Torture (CVT). We also
visited a variety of local institutions including three femaleheaded community based organizations in different lowerincome neighborhoods in Amman, a church, a church clinic,
a clinic specifically for refugees, a hospital, two vocationaltraining institutes, two language-training programs, a
number of Palestinian refugee camps (including Gaza
camp), and a day-long outing with Iraqi refugee families.

were long-time residents of Jordan. About 90 interviews
were held with Iraqis, 57 of whom were men and 33 were
women living in at least 10 different neighborhoods.
Interviews were also held with 36 Jordanians, Palestinians
with Jordanian citizenship, and Palestinians without legal
status in Jordan (in total, 22 women and 14 men). A smaller
number of Somalis and Sudanese refugees were also
interviewed. We were introduced to these refugees by one of
the only NGOs dealing with them, the International Catholic
Migration Commission (ICMC). After visiting a female
headed household in Amman, one of the co-authors was
introduced to five other single females and female heads of
household living within the same neighborhood. Although
there was a visible presence of young male Somalis in the
neighborhood, she was not able to interview any. We also
conducted seven discussion groups with Iraqi refugees at
a community-based center in East Amman and a private
clinic in West Amman. These groups included refugees with
serious medical conditions, those with chronic diseases, the
elderly, and those with no specific health related conditions.
To get a better sense of the overall Jordanian health care system,
we interviewed staff at Abt Associates regarding the USAIDfunded project (Health Systems Strengthening II), which
implemented a supplemental Iraqi refugee-focused project
described below, and officials from the Ministry of Health,
World Health Organization (WHO), and UN Relief and Works

The core of the research was interviews with Iraqi, Sudanese,
and Somali households in Amman, Sahhab and Zarqa, as
well as host country nationals and Palestinian refugees who

This paper is one of three products of our teamâ&#x20AC;&#x2122;s research on urban refugees in Amman and Cairo. The other reports focus on education, livelihoods, shelter and security as well as health care for refugees in these cities.
1

3

Agency for Palestinian Refugees (UNRWA). Members of the
research team also visited a refugee-specific clinic operated
by Caritas, a public primary health care center, privately
funded church-based health clinic (St. Luke’s Association
Clinic), an UNRWA clinic and a public hospital to observe
the settings in which health care services were delivered.

randomly selected and the numbers are not large enough to
generalize to the whole population, the resulting interviews
did demonstrate ethnic, gender and socio-economic diversity
within the specific geographic areas identified as having
significant refugee populations. The research methodology
included in depth, ethnographic interviews with individuals
and several hours of discussions with anonymous
groups of refugees to get at issues under consideration.2

The research was focused on geographic areas in which high
concentrations of refugees live; the majority of interviews
were held in Amman with 15 held in Zarqa. These areas were
identified through extensive interviews with stakeholders.
A snowball sample was used to identify refugees and host
country nationals. In order to obtain a representative sample,
local interviewers were chosen to reflect diversity in origins,
gender and socio-economic status. Interviewers were told to
reach out to as diverse a set of refugees and locals as possible
to reflect the population at large. While the sample was not

This report begins with background information on the
evolution of UNHCR’s policies on urban refugees, with
specific attention to its guidance on health services for
refugees. It then discusses the principal findings of the
research conducted between December 2010 and January
2012 (see Taylor 2012). The report concludes with the policy
issues raised by these findings and recommendations
for the UNHCR, US government and other stakeholders.

Background
The topic of urban refugees has received growing attention
as the numbers of urban refugees has increased. UNHCR
first promulgated policies specifically related to urban
refugees in 1997 with issuance of “Policy on Refugees in
Urban Areas” (see Kibreab 1996). The policy emphasized
assistance and solutions, treating urban refugees as a
“problem” resulting from unregulated movements.
Assistance was to be provided when needed, in a manner
that did not promote dependence on international aid.
The policy also discussed protection issues, noting, in
particular, concerns about “non-refoulement and treatment
in accordance with basic human standards.” The policy was
predicated on an assumption that the majority of urban
refugees were young men, although mention was made
of what were assumed to be smaller, potentially more
vulnerable groups that included women and children.

urban refugees as potential partners in designing new
approaches, rather than merely problems to be addressed.
The literature received a further boost with a special issue
on urban refugees in the Journal of Refugee Studies in 2006
(Vol. 19, No. 3). At the time of issue, UNHCR estimated that
18 per cent of refugees lived in urban areas, but in her
introduction to the special issue, Jacobsen observed that
“as urbanization rates increase globally, so do the number
and proportion of refugees and IDPs.” The Iraqi refugee crisis
generated additional research on urban refugees, triggered
by the outflow of the largest population of refugees finding
safety in mostly urban environments. UNHCR’s evaluation
of its response revealed continuing problems with the
agency’s urban refugee programs (Crisp et al. 2009).
The report discussed debates over the actual number of
refugees in these urban areas, particularly as compared to
the lower number of registered refugees. It also revealed
some improvement with regard to protection of the Iraqi
refugees, concluding: “the protection space available to
Iraqi refugees in Jordan, Lebanon and Syria has expanded in
a number of respects since UNHCR launched its operation,”
citing absence of significant threats of refoulement, relative
openness of borders, greater access to health and education
services, and the ability of some refugees to enter the
informal labor force despite formal restrictions on work. The
evaluation cautioned, however, that the situation was still
unstable and that there were reasons to be concerned about
the future security of the Iraqi refugees, particularly as they
exhausted their financial resources and found the barriers to
employment to undermine their well-being. The evaluators
further emphasized that the gains could be easily reversed
if international funding were reduced. Fagen’s research on
Iraqi refugees in Syria and Jordan in 2007 further warned:

In 1999, UNHCR’s Evaluation and Policy Analysis Unit
undertook an assessment of the policy framework,
commissioning case studies in New Delhi, India; Cairo, Egypt;
Nairobi, Kenya; and, Bangkok, Thailand. The evaluation
noted that the demographic assumptions of the policy
were not supported by the evidence—that, in fact, many of
the urban refugees lived in family units that included men,
women and children (Obi and Crisp 2011). The evaluation
found significant problems in the implementation of the
policy’s focus on self-reliance. For example, in Cairo, there
were two workshops to explore such program innovations
as providing micro-credit opportunities to women refugees
to start small businesses and offering vocational training,
but the Egyptian government refused to permit the
micro-credit program and UNHCR failed to find sufficient
resources for the vocational training program (Sperl 2011).
The evaluations also emphasized the tenuous status of
many urban refugees, which negatively affected both their
capacity for self-reliance and the protection problems
they faced. The case studies generally recommended
that the policy be reformulated to recognize the more
diverse urban populations and the considerable barriers
that they faced, but also urged the UNHCR to see the

Citizens blame the Iraqis for rising prices of real estate, rent
and food, for overcrowded schools and health facilities
and for shortages of electricity and water. As the report
shows, Iraqis are neither the sole cause of the rising prices,
nor are they a net drain on the two countries’ economies.

As agreed with Georgetown University’s Institutional Review Board on protection of human subjects, informed consent was obtained
from all respondents but no record was kept of the names or other identifying characteristics of the refugees or host country nationals
to ensure their privacy and security. Stakeholders were given the choice as to whether to keep their interviews anonymous or on the
record; the vast majority chose to be on the record.
6
Stefan Sperl, (2011) “Evaluation of UNHCR’s policy on refugees in urban areas: A case study review of Cairo”, EPAU/2001/07, Evaluation
Reports, Geneva: UNHCR.
7 Jeffrey Crisp, et al., (2009) “Surviving in the city: A review of UNHCR’s operation for Iraqi refugees in urban areas of Jordan, Lebanon and
2

equity,
prioritization,
rationalization,
partnerships,
participation, communication and evidence-based decision
making), the guidance gives priority to mainstreaming
of health care services, noting that “public health
services for refugees are made sustainable by being
integrated within the national public system whenever
feasible” (UNHCR 2011: 8). The guidelines also recognize,
however, that complementary refugee-specific services
may be needed, especially if mainstream services are
not available or appropriate to the needs of refugees.

These various case studies led to reconsideration of
UNHCR’s urban refugee policy, with promulgation of
new guidance in 2009. The new policy focused more
specifically on protection, with UNHCR emphasizing:
When refugees take up residence in an urban area,
whether or not this is approved by the authorities,
UNHCR’s primary objective will be to preserve and expand
the amount of protection space available to them and to
the humanitarian organizations that are providing such
refugees with access to protection, solutions and assistance.

Standards for refugees should be similar to those available
for nationals and, at the least, must meet UNHCR’s own
minimum standards for health services. Consistent with this
approach, priority should be given to ensuring access to
primary health care and emergency services, with referral to
more specialized medical care given lesser priority. Referral
is to take precedence over medical resettlement, however,
when feasible. With regard to specialty care, the guidelines
emphasize: “Referral is primarily a medical decision, based
on prognosis, cost and availability of specialist services
that takes place through a secure and transparent process”
(UNHCR 2011: 15). As resources vary from country to
country, the guidelines indicate that decisions on these
issues should be made at the country level and recommends
establishing a referral care committee and full transparency
regarding the criteria and policies that will be followed.

The new policy also focuses more directly on partnerships
to be forged with other UN agencies, host governments,
and, importantly, the urban refugees themselves. Among
the components of the new policy are providing reception
centers in urban areas, writing new procedures for
registration and data collection, ensuring documentation,
making refugee status determination processes more
efficient, continuing community outreach, fostering more
constructive relationships with urban refugees, ensuring
greater security, promoting livelihoods and greater selfreliance, ensuring access to healthcare, education and
social services, meeting material needs, and promoting
durable solutions. With regard to durable solutions, the
new policy emphasizes that urban refugees should be
neither advantaged nor disadvantaged in finding durable
solutions as compared to camp and rural populations.
Recognizing that resettlement has been a draw for some
refugees to relocate to urban areas, believing they have
greater access to resettlement there, the new policy notes:

In 2012, UNHCR added guidance specifically regarding the
enrollment of refugees in public and private health insurance
schemes. Recognizing the complex range of health insurance
options in most countries, UNHCR encouraged its field
offices to assess the extent to which insurance coverage was
feasible, affordable and appropriate to the health needs of
their beneficiaries. The guidelines noted a number of benefits:

Resettlement activities will be tailored to the
specific characteristics of each urban area and
will be managed in a way that mitigates the risks
associated with resettlement.…To avoid unrealistic
expectations and the security problems that they can
generate, UNHCR will keep refugees fully informed
about resettlement prospects and procedures.

Improved access to health services and financial
protection are clearly the two largest benefits. Indirect
benefits include an official piece of documentation (the
health insurance card) that may protect refugees from
harassment by authorities and provide refugees with
a sense of belonging and security (UNHCR 2012: 6).

In 2011, UNHCR issued further guidance on health care
services for urban refugees in a document entitled
Ensuring Access to Health Care: Operational Guidance
on Refugee Protection and Solutions in Urban Areas. The
guidelines take a multi-sectoral approach, noting that:

The main impediment to use of national public and private
health insurance programs are the cost of premiums and copayments, particularly for refugees with very low incomes;
restrictions on coverage for pre-existing conditions; and
limited coverage or high deductibles and co-payments
for hospitalization and expensive chronic treatments for
conditions such as kidney failure dialysis. UNHCR recommends
seeking insurance policies that are comparable to those
available to nationals and cover as broad a range of services
as possible, but it recognizes that such policies may be costly
and beyond the reach of the most vulnerable refugees.

The health status of refugees will not be improved by health
services alone; the underlying determinants of health must
also be addressed by improving livelihoods and income,
food security and nutrition, housing, education and
access to water and sanitation services (UNHCR 2011: 3).
Organized around nine key principles (access, integration,

Health Care in Jordan
Jordan has a complicated health care system with relatively
good outcomes for a developing country. In 2009, the
World Bank reported, “Due to high quality health care
and improved access, the life expectancy at birth in 2009

was 73 years”. The crude mortality rate for under five-yearolds was 22 per 10,000 live births (The World Bank 2012).
The Ministry of Health (MoH) has lead responsibility
for
health
care
in
Jordan.
WHO
reports:

5

According to the new Public Health Law No.54,
issued by a Royal decree in 2002, the Ministry of
Health is responsible for health matters pertaining
to all residing in the Kingdom, and in particular:
Protecting health through providing preventive
and curative services as well as monitoring
responsibilities:

•

Organizing and supervising health services provided
by the public and private sectors

•

Providing health insurance for citizens within
available resources

•

Establishing educational and training health
institutions managed by the MOH (The World Bank
2012: 37).

Ministry of Health officials estimate that about 70 per cent of
the population is insured. This percentage does not include

Uninsured Jordanians can go to the Royal Court to petition
for an exemption from insurance requirements for tertiary
care. Ministry of Health officials noted that about 20 per
cent of MoH expenditures are on uninsured. Regarding
tertiary care, MoH officials commented that they “can’t give
advantage to Iraqis over local population” and expressed
concern that they may not be able to continue to afford
costs of treating them as insured Jordanians for primary care.

Access of Iraqi Refugees to Health Care
Iraqis have access to primary care on the same basis as all
Jordanians. They are treated as uninsured Jordanians for
purpose of secondary care3 and as uninsured non-nationals
for tertiary care. By law, hospitals must provide emergency
care. If Iraqis visit an emergency room outside of the hours
during which the refugee-specific clinics (see below)
operate, hospital staff will treat the emergency. Once the
patient’s health is stable, the hospitals determine which
clinic is to be contacted and steps are then taken to ascertain
who will pay for the treatment. This process is opaque,
uncertain and lacks consistency however; and the interview
team heard about Iraqis who paid for treatment out of
their own pockets because they believed that the refugeespecific clinics, such as Caritas, could not or would not pay.
In practical terms, Iraqi refugees are eligible to seek
health care at primary health clinics operated by the
Jordanian government. For children, the coverage includes
immunization and basic preventative health care while
adults have a co-payment for primary care. Uninsured
Jordanians have a co-payment for treatment of and
medication for such chronic diseases as diabetes and
hypertension and Iraqis are similarly treated. Iraqis are
not eligible for subsidized government tertiary services.
In accordance with its guidelines on health care in urban
settings, UNHCR Jordan has a process for determining if
it will cover tertiary costs not covered by the Jordanian
system through an Exceptional Care Committee (ECC).
Complementing the Jordanian health care system are
two refugee-specific primary health providers; Caritas
International Jordan and JHAS receive funds to provide
primary and some secondary care to refugees in their
clinics. Caritas Jordan was established in 1967 in order:
To respond to the humanitarian crisis caused by the
six-day war with Israel. It has since then developed into
a dynamic organization that contributes to the fight
against poverty and helps to promote development
in various sectors of Jordanian society (Caritas 2009).
Caritas works with Iraqi refugees, migrant workers and
3

vulnerable Jordanians. The organization provides medical
assistance (In/Out patient medical care); humanitarian
assistance (food and non-food items, clothes, tickets); home,
hospital, factories, detention centers and prison visits; and
awareness sessions for migrant workers on important topics
such as HIV-aids and chronic diseases. Caritas implements
the Health Medical Care & Awareness Training for Iraqi
Refugees and Asylum Seekers in Jordan, which provides
basic medical, dental and optical care at centers in five
centers (Zarqa Center, Huson Center, Karak Center, Fuhais
Center and HAJO Center). Through its project, Health and
Medical Support for Urban Refugees in Jordan, Caritas
also provides medical assistance to other refugee groups,
including Somalis, Sudanese, Syrians, Egyptians, Sri Lankans,
Pakistanis, Turks and Chechens recognized as refugees by
the UNHCR. Medical services for non-Iraqis are provided at
Caritas General Practitioner and Dental Clinics in Amman,
Zarqa and Huson. These health services were initially free to
all refugees, then restricted to registered refugees, and now
have moved to a nominal fee for service. This fee is slightly less
expensive than the regular consultation fee at Caritas clinics.
The fees are more expensive, however, than the cost at public
health centers. For more serious medical concerns, Caritas
usually refers patients to its two private partner hospitals,
the Italian Hospital or Luzmila Hospital, or on occasion to
the largest public hospital in Amman, al-Bashir Hospital.
The Jordan Health Aid Society (JHAS) was established under
the decree of The Ministry of Interior, in July 2005. JHAS runs
clinics for both Jordanians and refugees. JHAS has more
than 50 members, including doctors, engineers, lawyers,
pharmacists and nurses, who work with governmental
organizations, in the private sector, as teaching staff at
universities, or environmental activists. In collaboration
with the International Medical Corps (IMC), JHAS provides
primary and secondary services to Iraqi refugees and other
UNHCR registered beneficiaries. More specifically, JHAS
operates three static clinics in Amman, Irbid, and Zarqa
and one Mobile Medical Unit (MMU); is to provide at least
37,000 consultations for primary health care (PHC) services
(35,000 through three static clinics and 2,000 through MMU);

Uninsured Jordanians are responsible for 25 per cent of the costs of secondary care.

6

Books

•

children aged six and under, all of whom (nationals and
non-nationals) are covered for primary and preventative
care. According to WHO, “The Royal Medical Service (RMS)
is the largest health insurer (27%) followed by MOH (19.5%),
UNRWA (11%), private firms (8.8%) and university hospitals
(2%)” (The World Bank 2012: 8). This appears to be the inverse
of the situation pre-2001, when about 40 per cent of health
care was provided by public authorities and 60 per cent by
private ones. Public expenditures on health care doubled
from $180 per capita in 2001 to $357 per capita in 2010.

conduct clinic-based health education sessions for 9,000
individuals; and recruit chronically ill patients, primarily
with hypertension and diabetes, to participate in Healthy
Lifestyles campaign. JHAS also has a central laboratory. The
project is funded and supported by the UNHCR in Amman.
IMC has been engaged in capacity building activities
with JHAS since 2008. In additional to its collaboration in

Jordan, IMC also has helped build the capacity of JHAS to
respond to crises in Libya, Yemen, Sudan and Gaza. JHAS
does not accept Jordanian government money but has
good relationships with the Ministry of Health. They refer
tertiary care patients to UNHCR for approval. JHAS is more
likely to refer to public hospitals than Caritas, which refers
primarily to two private hospitals with which it has contracts.

Iraqi Attitudes about Health Care
Iraqi refugees’ expectations about healthcare access and
cost derive from years of free services and medication
in Iraq and the fact that many are older and have
chronic diseases (e.g., hypertension and diabetes).
As one participant in a group discussion noted:

All respondents expressed preferences for the
health care they received in Iraq over that available
in
Jordan.
Representative
statements
included:
The health care isn’t good because there isn’t
a health system or culture of health care here.

It is simple. There are three groups of us—those with
special needs and disabilities, those with chronic
illnesses like high blood pressure, hypertension and
diabetes; and then those who become ill suddenly.4

There is hardly anything in the way of health
insurance and the quality of medical care in public
hospitals is fairly poor. Private care is far more
expensive here in Jordan than it was in Iraq. Also, the
medicines are far more expensive here than in Iraq.

According the UNHCR statistics for the end of 2010,
there were 4,018 Iraqis with a “critical medical condition”
(13.1% of the total) and 837 with disabilities (2.7% of
total). Another 713 (2.3%) were recorded as survivors of
torture. People with disabilities encounter many obstacles,
physical and social, to carrying on their lives and, when
combined with poverty, even their ability to survive.
Some

of

the

disabilities

are

After leaving Iraq [in February 2004], we didn’t find
good health care as we did in Iraq because here they
don’t just treat anyone—only if there is an agreement
with an organization or a health center or hospital.
The significance of such statements lies not in their factual
accuracy, which is questionable based on what is known
about the deterioration in the standards of health care and
availability of medicines in Iraq. It is rather in the personal
reflection on the past and its relationship with the present.
By far the most common complaint we heard from our
respondents about health services and medication in
Jordan overall relates to their cost and long waiting times for
appointments, with some concerns expressed about what
they perceive as lower quality of medical care and difficulty
in negotiating a seemingly opaque system among public
and NGO providers. Those who are initially registered with
Caritas, for example, may be turned away by JHAS and vice
versa. Another common reason cited was perceptions of
misdiagnosis on the part of Jordanian doctors and ineffective
medication. Coming from a country in which cheap and
branded medication was readily available before the 1990s,
there is mistrust among Iraqis of generic Jordanian-made
medication, despite its stringent checks and quality assurance.

war-related:

I was hit by an IED explosion, and I lost my right eye,
my face was disfigured, and I lost muscle in my feet
and hands and other areas of my body. I suffered a
lot of hardships and had a lot of surgeries. (Interview)
Other interviews referenced various forms of cancer, heart
disease, and other debilitating illnesses. Thalassemia—
an inherited blood disorder that results in excessive
destruction of red blood cells, which leads to anemia—
is a serious condition for many Iraqi refugee children.
Some refugees spoke of coming to Jordan through a
program operated by Médicins San Frontières/Doctors
without Borders: “MSF took me to Jordan to complete
treatment for my left foot because of the lack of good
health care in Iraq. My foot is improving a lot because I
had two operations paid for by MSF” and “I applied to the
French organization Doctors without Borders, and after
6 months, they contacted me and agreed to take me to
Jordan for treatment. I had a lot of surgeries.” Intended to
be for temporary stays in hospital, some undoubtedly
return to Iraq but others register with UNHCR in Jordan.
Respondents in this program expressed fear of return to Iraq:

Cost was a universal complaint, largely derived from the large
number of Iraqis who are older and have chronic diseases that
need regular medication. Many came with the expectation
that they would get free check-ups and pharmaceuticals and
that the medications would be name-brand, not generics.
Many Iraqis do not trust pharmaceuticals manufactured in
Jordan (though all health care stakeholders said that the
medications were of high quality, even sold to countries like
Portugal and praised Jordanian manufacturing). Even the
generics, though, cost the Iraqis more than they thought
they could afford, particularly with the reductions in cash
transfers that they expected (which UNHCR confirmed), the
shift at Caritas from free medicines to what is effectively
coverage of only 1/3 of cost of medications (one month
out of three is free), and fee for services at clinics. The lack

I applied to UNHCR to stay out of fear for the fate of
my family, who had remained in Iraq. Months passed,
and my wife contacted me to say that my oldest
son had been kidnapped. I refused my surgery and
returned to find my son, even if they wanted to kill
me…I contacted the doctor who had treated me at
Doctors without Borders and arranged my reception
in Jordan, along with my family. I was also able to add
some other family members to my file with the UN.
4

The respondent appeared to be referring to those who need emergency services.

7

of employment prospects (authorization and actual jobs)
make many of the Iraqis especially worried about how
they will pay for their secondary care and medications.
The elderly are especially vulnerable. In a discussion
group with elderly Iraqis, the acute need for affordable
medicines is evident. A middle-aged woman who suffered
from diabetes, received prescriptions from the doctor, but
could not afford the medicines. “I visited Caritas twice, but
they did not do anything for me.” Her medication costs 50
Jordanian Dinars each month, and each month she must
wait to receive 110 Jordanian Dinars in financial assistance
from the UN before visiting the doctor. She ended the
conversation: “I am lucky I live with my son. He pays the
rent and puts food on the table. My situation is very bad.”
In the same group of eight participants, five people
suffered from diabetes. A man in his early seventies spoke
of being unable to afford his insulin due to his financial
situation (Anonymous Discussion Group 6, January
2012). Living alone, he receives 75 Jordanian Dinars each
month in financial assistance. The monthly supply of
insulin amounts to 18 Jordanian Dinars every month. At a
private pharmacy, he buys a packet of ten syringes for 1.5
Jordanian Dinars. So as to save money, he injects himself
at home using alcohol as a disinfectant. In both interviews
and group discussions with Iraqis, there is a sense of
increasingly hopelessness and despair over where they can
obtain medicinal supplies for secondary health concerns.

Others
echoed
One respondent

the
in a

situation
and
frustration.
group discussion observed:

Private doctors are very, very expensive and they
[refugees] cannot meet the high cost. After obtaining
an appointment at Caritas, you have to wait a
month, and the sick cannot wait. They suffer a lot.

Most of the Iraqis we interviewed continue to seek their
healthcare at the Caritas or JHAS clinics that cater to Iraqis,
but most were familiar with the public primary health care
centers and hospitals in Amman. When pressed to answer
whether they had ever tried a public primary health care
center, approximately half of the participants in each
group shook their heads and said they had not used one.
Perceptions and prejudices on the part of Iraqis about
public health centers clearly constitute an obstacle to their
integration into the public healthcare system. When asked
why they did not use public health centers more during
discussion groups in January 2012, Iraqis cited overcrowding,
long wait times and poor quality care as reasons for
choosing the private or NGO service providers. Similarly, the
visits of one international NGO to Iraqi households in 2011
led them to conclude that less than 20 per cent of Iraqis
had ever used public services (Anonymous Stakeholder
Interview 19, January 2012). Reasons given were similar to
those heard during our discussion groups: long waitingtimes, rude doctors and inconvenient locations. They also
felt that they are discriminated against as Iraqis. They were
also unfamiliar with the process for registering with the
public facilities and what services are available to them.

A father of two sick children spoke of his family’s anxiety
as a result of reduced services—a sentiment conveyed by
many families. Roughly around the beginning of 2010, the
treatment from Caritas slowed down. The children’s monthly
medicine costs amount to approximately 700 Jordanian
Dinars, but the monthly assistance from the United Nations
does not begin to cover it. This has affected the psychological
state of his children, whose fear of death increased.
Feelings of despair and frustration are also shared among the
NGO service providers themselves. A stakeholder observed
in January 2012, “Once we had a lot of money, around 1500JD
per patient per disease. Now we have 500JD per patient, but
these funds are finished before the year is out.” He added:
“Before, we were encouraging them [Iraqis] to go public, and
now we are pushing them.” In conversations with Iraqis about
the perceived change in health services, they frequently
mentioned the drying up of services “at the end of the
project year”, as NGOs ran out of money to pay for medicines
and minor operations. The vulnerability and dependency
of these individuals, who have grown accustomed to the
provider-beneficiary relationship at the crux of humanitarian
aid-giving, is clearly visible. Such short yearly funding cycles
geared towards emergency relief in times of crisis are illsuited to and preclude sustainable approaches to coping
with the health needs of those in protracted displacement.

Discussions on health with Iraqis for the purposes of this
research frequently descended into the recounting of
numerous “sagas” of referrals or “to-ing and fro-ing” between
service providers. A young construction worker remained
silent and somewhat aloof throughout one discussion
group of Iraqis with a variety of health problems, nodding
occasionally in agreement with more vocal participants
around the table. When asked about his experience of
health care in Jordan, he began to recount the waiting he
had endured over the previous two-month period. One
morning, he fell down suddenly and lost feeling in his
upper body. After going to Caritas, he was told to wait two

The discussions with both Iraqi refugees and stakeholders
indicated that the system for treatment of tertiary
conditions, such as cancer or Thalassemia (a genetic blood
disorder that is common in the Mediterranean region) is
the most problematic issue in Jordan—for both refugees
and uninsured Jordanians. In both cases, those requiring

8

Journal Articles

months for an appointment. Concerned, he decided to visit
a private pharmacy for a consultation of sorts and, more
importantly, a dispensing of medication—an increasingly
popular option among Iraqis. After the numbing sensation
continued for three more days, he visited the Emergency
Room of the Italian Hospital late one night, where he
showed the doctor his UNHCR papers. Although Jordanian
law requires that those in need of emergency care must be
treated immediately and the cost accounted for later, cases
not considered a life-threatening emergency are unable
to receive treatment if they visit the ER outside the limited
operating hours of the NGO clinics. Indeed, in what has
become the norm in a system marred by inconsistencies,
he was told by the doctor that “nothing could be done”
without an “official referral” from Caritas. After visiting a
public primary healthcare center the following day, he was
referred to al-Bashir hospital for an appointment with a
neurologist. Unable to wait the two months for diagnosis
with the gloomy prospect of more referrals and desperate
to return to work, he eventually visited a private doctor
and paid 20 Jordanian Dinars for a consultation fee. When
told he would need to pay between 150- 200 Jordanian
Dinars for an MRI scan, he resorted to more waiting in
a life, he implied, is increasingly dictated by waiting.

Journal Articles

treatment must seek approval by a “higher authority” to
get treatment (UNHCR’s Exceptional Care Committee for
refugees and the Royal Court for Jordanians). Because
of the high cost of tertiary treatment, approvals are not
automatic. UNHCR has a limited budget and recognizes that
one case could wipe out the entire budget for the year. The
absence of a clear policy of guidelines, long waiting lists
and diminishing funds means that those awaiting a verdict
from what they see as the health jury are exposed to more
uncertainty, depending on others to decide their futures
(Mowafi and Spiegel 2008: 1714). The opacity and ambiguity
inherent in the health system is further exemplified
by the arduous process of referrals, which constitute a
source of anxiety and frustration for Iraqis. It proves to be
financially, mentally and physically exhausting as patients
are sent to various healthcare providers across the city.

Of course, on the question of psychological health,
she is very broken on account of the fact that she is a
woman who cannot provide what her children require.
Tertiary care proved to be the most difficult issue to address
because of the serious ethical and practical issues it raises:
Operational ambiguities (e.g. not knowing what has
already been expended for health care, what excess
the budget might permit, what process to follow for
higher level permission, will future funds be available for
expensive chronic cases) make a difficult ethical decision
even more difficult (Leaning, Spiegel and Crisp 2011: 2).
Leaning et al. conclude that, in making exceptions,
the advice and guidance from stakeholders, including
members from different refugee and host communities
and possibly donors, would be most valuable in framing
and legitimating options. Fairness issues would demand
the highest level of transparency, so that everyone
involved at all phases would know what was possible to
permit as an exception and what was not (Leaning, Spiegel
and Crisp 2011: 6). Ideally, this approach provides what
solutions can be brought to an impossible reality that can
only be truly solved by mitigating funding deficiencies.

The deterioration in treatment and service provision for
Thalassemia patients highlights the issues. UNHCR was
able to fund treatment for Thalassemia cases until 2009
when the costs proved prohibitive given the level of donor
support. One of the respondents in a group discussion has
two children with Thalassemia. As part of their treatment,
both children need two units of blood given to them
every month, at a cost of 50 Jordanian Dinars per unit.
This amounts to 200 Jordanian Dinars per month, and the
family receives not more than 220 Jordanian Dinars per
month in financial assistance from UNHCR. In addition
to monthly blood transfusions, the children need to take
daily tablets. The family income means they cannot afford
to pay for this so she resorts to begging in hospitals. She
admitted that sometimes her children have only three
tablets per month. When asked how she will find the next
tablets for her children, she replied, “God will give me them.”

The World Health Organization has engaged in a variety
of activities to assist Iraqis with chronic health problems.
For example, WHO provided the Jordanian Ministry of
Health with two procurements of drugs to the value of $1.7
million for Iraqis with chronic and mental health problems.
WHO also supported the treatment of cancer, thalassemia
and multiple sclerosis cases through Memoranda of
Understanding (MoUs) with care providers who had the
capacity to cover these cases. Currently, under a grant from
the U.S. Department of State Bureau of Population, Refugees
and Migration (PRM), WHO is working with UNHCR and its
implementing partners to expand coverage of treatment
for serious illnesses.5 Under the program, if the cost of the
Iraqi beneficiary’s care is less than 500JD, Caritas or JHAS
will cover the cost as implementing partners of UNHCR.
If the cost exceeds 500JD, the case would be referred
to the ECC, which includes representatives of WHO and
UNHCR and two other physicians. WHO covers the cost
of approved cases. Since its implementation at the end
of February, WHO has been supporting an average of 60
cases per month with various hospital based care needs.
The funding obtained from PRM expires in August 2012.

Others interviewed also spoke of begging for medications,
or in other cases, going into debt for the sake of paying for
expensive medical treatment. In one interview, an elderly
woman spoke of borrowing money so that her husband
could receive treatment for his cancer at the public al-Bashir
hospital. After he passed away, she was forced to take out
more loans to pay for her own gall bladder surgery. To this
day, the widow is in debt, living with her daughter in a poor
neighborhood of Zarqa. During the same discussion group
of eight Iraqi men and women who had family members
suffering tertiary illnesses, one parent’s desperation was
visible in her tears when describing her son’s medical needs:
I need four boxes of colostomy bags each month for
my son, but each box costs 40 Jordanian Dinars. A
bag is not like tablets. It’s not like you can just run
out and try to make do. My son doesn’t have nerves
developed and so he can’t control his bowel movements.

Efforts have also been made to encourage the Iraqi
government to provide support for its citizens in Jordan
who need expensive treatments or help with chronic
care problems. The Iraqi Health Attaché in Amman has a
mandate to facilitate treatment in Jordan for Iraqis coming
from Iraq for treatment, but the Iraqi government has not
extended the assistance to include Iraqi refugees who
were already based in Jordan. Despite these initiatives,
according to one health official, more resources and
information must still be made available for Iraqis in
terms of what their options are surrounding tertiary care
(Anonymous Stakeholder Interview 28, January 2012).

Similar
distress
was
conveyed
to
an
Iraqi
interviewer by a woman whose son’s speech
and hearing was damaged in car bomb attack:
She cannot pay the costs of the operation, because
it cost $20,000. Of course, she did not any receive
assistance until now, whether from humanitarian
organizations or from the United Nations. The services
have been reduced now to only issues like…influenza,
or some small operations that require treatment. She
has gone to Caritas many times about these matters.
5

In 2010/2011, UNHCR denied about 30-40 per cent cases referred to the ECC but WHO hopes to lower this rate.

9

Mental Health
Anonymous interviews with Iraqis revealed countless
stories of highly personalized violence and trauma, with
the vast majority of accounts alluding to torture, routine
abductions and targeted killings of family members:
One time I was going to work and so I left the children
with one of my relatives. When I returned to the house,
I found that there had been an ambush and my children
were tied up in one of the rooms. They were crying and
screaming in fear…I was arrested in front of my children
and they were left alone screaming in the house that
night. This horror deeply affected them psychologically.
After being imprisoned for seven months, I was set free,
but I was mentally and physically tortured and threatened.

The principal provider of mental health services to refugees,
the Center for Victims of Torture (CVT), related that the need
for services among Iraqis outweighs the available resources.
Ninety-five per cent of CVT clients are Iraqi. About 25-30 per
cent of clients are children/young people. There is a waiting
list of 300; CVT had to stop outreach because it was unable
to provide services to everyone on the waiting list. Finding
mental health services for refugees in the Jordanian mental
health system has proven difficult because of inadequacies
in the mainstream services. Most care is provided in tertiary
institutions, a level of care that is considered old-fashioned
and inappropriate to the type of problems evidenced by
refugees (and most Jordanians). Several respondents noted
the need for better coordination between the Jordanian
Ministries of Health and Education and the refugee
service agencies in identifying appropriate responses to
the growing demand for mental health care, particularly
among children. Many Iraqis with children in Jordanian
state schools complained of a lack of support in schools
for their children, several of whom suffer from bullying
due to problems of involuntary urination, anxiety attacks
and other psychological effects of events witnessed in Iraq.
UNICEF has worked to convince the Ministry of Education
that psychosocial support for children falls within its remit.
However, whilst the government has been receptive to the
idea of training teachers, the stigma surrounding mental
health issues persists in Jordanian society and in the majority

In many cases, the refugees appear to fixate on medical
problems, worrying over where they will go when they get
sick or who will pay for their treatment. The intention is
not to trivialize medical concerns of Iraqis. Rather, the lack
of activity in daily life and access to employment forces
many to dwell on medical concerns and exacerbates mental
health problems. Other factors that contribute to mental
health problems include trauma stemming from violence
in Iraq and anxieties about their future status in Jordan
or upon resettlement (see below). Psychosocial activities
administered by NGOs and CBOs have been relatively
successful in providing distractions for Iraqis outside the
home. Initiatives include women’s craft cooperatives, cookery
classes, hair and beauty sessions, as well as some English and
computing classes. Some of these activities, while a means
of overcoming isolation, were found to be lacking in utility
and different from the desires and perceived needs of Iraqi
beneficiaries, who wished to learn more practical vocational
skills. There was also a gender bias towards women in the
range of course offerings. Interestingly, the research team and
various stakeholders observed that depression and isolation
was most visible among young Iraqi males who, unable to
work or study and fearing trouble, confine themselves to
the home. The role of the provider has vanished for many
Iraqi men, leading to increased vulnerability and feelings if
impotence. Whereas women continue to fulfill their roles
as wives and mothers, “albeit in worsened conditions”, men
face difficulties in adapting to the vacuum of pro-activity
(Sassoon 2009). Women in more than one discussion group
talked of meeting each other at craft cooperatives, shopping
excursions and family planning clinics, whereas men had
very little to say about their daily activities outside of the
house. The gendered divide was also implicit in a discussion
with elderly Iraqis in January 2012. When asked to describe
what they did every day, elderly men in one discussion group
struggled to respond. Women spoke fondly of new friends
they had made since arriving in Amman, while men spoke
of watching television, walking to the market and reading
because they felt alone and unable to leave the house in
an unknown city. In this regard, collaboration between
INGOs and local CBOs who might hold weekly social events
for local residents of the area is crucial in allowing for
increased interaction and integration between Jordanians
and Iraqis, regardless of the duration of their stay in Amman.

Mainstreaming Intiatives
A project funded by the Bureau for Population, Refugees and
Migration and implemented by IRD was aimed at addressing
some of these access issues in the mainstream system. IRD
did a baseline survey during the period between September
2010 and August 2011 that showed that 70 per cent of Iraqis
were familiar with public clinics but would not try them,
saying they didn’t know where the clinics were, the clinics

were too crowded or offered bad services, or they didn’t know
how to get services, etc. The findings also referenced need
for capacity-building among health professionals on chronic
diseases, mental health issues, STD tests. These programs
showed a particular need to build awareness among health
professionals about the effects of violence on refugees.
IRD implemented a pilot program last year that placed

10

Journal Articles

According to one INGO worker and mental health
expert, over the course of time, the majority of those
Iraqis suffering severe trauma have received treatment
and the stigma surrounding mental illness within the
Iraqi community has dissipated somewhat (Anonymous
Stakeholder Interview 29, January 2012). Yet, one also suspects
a greater number of “silent sufferers” who remain unreferred and subsequently untreated, particularly among
those who have been in Jordan for longer periods.

of schools, there continues to be only one school counselor
for 500 students or more (Anonymous Stakeholder Interview
29, January 2012). Close collaboration among donors, the
Ministry of Education, the Ministry of Health, IGO and NGO
service-providers could contribute to the improvement and
continued decentralization of mental health care in Jordan,
for the benefit of both refugee and host communities.

Journal Articles

volunteer “guides” or contact persons in six health clinics
in areas with large numbers of Iraqis. The guides help
the refugees navigate the public primary health clinics.
Originally, the clinics had separate hours for Iraqis but this
practice led to tensions with Jordanians. Iraqi volunteers
asked for policy change to integrate refugees into regular
scheduling. Exit interviews for those who received services in
the clinics generally showed a high level of satisfaction, with
86 per cent saying they were satisfied. IRD kept a record of
actual waiting times at the clinics; they tended to be under 30
minutes. The program is being expanded to 14 clinics in 2012.
IRD also trained Iraqis to do home health visits. The volunteers
refer vulnerable refugees to IRD’s programs as well as other
resources available for them. About 10,000 were referred to
public health clinics and about 2,500 went (FY 2010). In the
first quarter of FY2011, 4,500 were referred and more than
1,000 followed up. IRD also did workshops for providers
to break their assumptions (Iraqis won’t follow rules, give
doctors a bad time, are aggressive, etc.). Receptionists and
others would ask for identity documents issued to Jordanians,
not realizing that UNHCR documents were equivalent.
As part of the mainstreaming of Iraqis into the public
healthcare system, an information booklet entitled “A
Guide to Healthcare Services offered by the Ministry of
Health to Iraqi Refugees in the Hashemite Kingdom of
Jordan” was published by the Ministry of Health, WHO,
UNHCR, UNFPA and IRD. The blue booklet, funded by the
Australian government, was designed to be both lucid and
comprehensive so as to prevent the spreading myths and
to encourage integration, with twelve sections covering
everything from emergency services to dentistry. Over
the past four years, it has been widely disseminated to
Iraqis by UNHCR and its implementing partners. It is visible
in the waiting rooms of most NGO clinics, but its efficacy
in conveying the message to Iraqis remains unclear. Few
Iraqis admit to having referred to the guide in times of
need, and one representative from an international NGO
working with Iraqis acknowledged that: “These information
booklets are not the best option. They are boring to read
and there are some people who are illiterate and cannot
read them.” Rather, according to NGO workers, the most
appropriate form of communication is by phone call or word
of mouth. Iraqis in Jordan tend to reside in the same areas,
where both there are NGO services available and the rent is
more affordable. Thus, many hear of services from friends,
classmates, neighbors and those they meet at UNHCR.
Understanding and quashing prejudices on the part
of Jordanian staff has also been crucial to facilitating
integration of Iraqis into the public health system.
Discrepancies in the attitudes and understanding of staff
has only increased mistrust among Iraqis, and reinforced
negative preconceptions of the treatment offered at public
health centers. In late 2011 and early 2012, the Ministry of
Health held a series of workshops in communication skills
for staff and medical professionals at primary healthcare
centers. It was found that Jordanian medical providers
also had their own assumptions about Iraqis, regarding
them as difficult, aggressive and with little regard for
rules. Explanations of the rights and entitlements of Iraqis
in Jordan, as well as training in how to “deal” with Iraqis
who might be suffering from trauma and mental health
problems, was also intrinsic to the workshops. However,

understanding and international donor-funded training
can only breed a certain amount of compassion. There
is the constant danger of patience wearing thin on the
part of the Jordanians and the Jordanian government,
the latter of which is under no obligation to play host.
A second project, funded by the U.S. Agency for International
Development (USAID), the Health Systems Strengthening II
project, took a different approach to mainstreaming health
care. The Ministry of Planning and USAID, with input from
UNHCR, UNICEF and the Ministry of Health, agreed to increase
the capacity of three public hospitals in areas in which large
numbers of Iraqi refugees reside. The focus of the capacitybuilding was to improve emergency room infrastructure
and obstetric services. The hospitals are in East Amman and
Zarqa, Two are general hospitals and the third is Al Bashir, the
principal referral hospitals. The supplemental Iraqi refugee
funds were combined with regular USAID funding on this
project. The aim was to address Jordanian government
concerns that the Iraqi refugees were overwhelming services
in these hospitals and Jordan was not being compensated for
the cost of integrating refugees into these hospital services.
There was also concern that a parallel system was developing
for refugees (e.g., Italian and Lazmila Hospitals) that was
unsustainable in longer term. There has been no systematic
evaluation to see the impacts on refugees or the broader
population, but USAID’s sense is that the increased capacity
generated by the HSS II project (not just via the refugee
funds but in general) is beneficial for both populations.
Refugee service providers did not appear to question the
validity of this approach but they did express frustration
that they have not been able to coordinate as effectively
with HSS II as they might have wished. This was expressed
especially by IMC, which works with the Jordanian Health
Aid Society (JHAS). IMC would like the MoH to build
relationships with local health clinics run by NGOs. JHAS and
IMC interlocutors spoke of the Jordanian health care system
as having three parts: public (as described), private and nonprofit. So far, the non-profit sector is the least defined, but
JHAS certainly sees itself as part of the Jordanian health
care system, even though they are not publicly funded.
The linkages with IMC seem to have reinforced JHAS’ view
that building the capacity of the NGO sector is necessary
to improving overall health service effectiveness in Jordan.
Access to primary healthcare for Iraqi refugees appears to
be between the Palestinian refugees on the one extreme
and Somalis on the other. Palestinian refugees have access
to UNRWA primary care facilities, which are generally
considered to be well-run and provide high quality care.
Somalis, on the other hand, even when registered with
UNHCR, do not necessarily feel that they have full access
to services and face language barriers and discrimination.
At the secondary and tertiary levels, all of these groups
face many of the same problems and cost barriers.

Mainstreaming and the
Prospect of Durable Solutions
Refugee access to and use of health services is tied to
and dependent on the prospects for the three traditional
durable solutions for refugees: return, local integration
and third country resettlement. The Iraqis whom we
interviewed categorically ruled out return to Iraq at this
time. They cited ongoing violence and lack of national

11

reconciliation or transitional justice as barriers, also
noting issues of highly personalized violence that have
not been resolved. Indeed, many stated they fear reprisals
and revenge should they return to Iraq. They also noted
problems of housing and food shortages in Iraq. Some of
those with chronic health problems observed that the Iraqi
health sector is only beginning to recover from sanctions,
war, internal displacement and medical brain drain, etc. In
particular, mental health care is still relatively weak in Iraq.
Respondents also noted that it is expensive to live in Iraq
and said that the Government of Iraq offers menial financial
incentives for returnees. There is also limited employment—
particularly in the central and southern regions. The
respondents were skeptical that the conditions in Iraq
would improve significantly in the short to medium term.
One of the NGO service providers described the reactions
of Iraqis in Jordan as very negative and “aggressive” when
they tried to introduce the idea of return into their projects.
Given the high level of reluctance to consider repatriation,
most service providers do not introduce the topic.

Resettlement is the most notable solution that affects
how refugees see health services and how health services
see refugees. Some of those with tertiary needs are in the
resettlement pipeline but long waits for approval mean
some won’t survive. Among resettlement countries, only
the United States appears to be medical-need blind in
acceptances; other countries often turn down applicants
with serious medical problems. U.S. processes are very slow,
though, because of the multiple security checks required
of refugees before they are accepted for resettlement. In
at least one case, a refugee family expressed concern that
a very seriously ill family member would die before all of
the clearances were approved, even though they had been
determined to meet all other admission requirements.
Resettlement options also affect mental health. One
respondent noted: “I have been in Jordan for a long time,
far from my country. There is a lack of resettlement and a
lack of stability. My current situation is having a negative
effect on my mental state.” Bader et al. posit that fluctuation
in mental health needs over time is associated with beliefs
that residence in Jordan is temporary, making Iraqis less
likely to immediately adapt to their new surroundings and
creating long-term psychosocial problems (2009: 317).
Mental health problems are exacerbated, and often seem
to present themselves as physical illness, by the fact that
they are unable to work under Jordanian law. Rather than
rediscovering self-worth and financial independence in
exile and engaging with people on a daily basis, it was clear
from interviews and discussions with Iraqis that much of
their time is spent confined to the home—often waiting
for phone calls from IOM Amman about resettlement.

Policy Issues
In an urban environment, more effective linkages between
refugee/relief and development funding and programs are
essential. The needs and issues faced by refugees are common
to Jordanians who are uninsured and face barriers to their
health care. We heard many of the same complaints about
waiting times, quality of services, etc. from the Jordanians we
interviewed. At the beginning of the crisis, it made imminent
sense to have a parallel system that was attuned to the needs
of the refugees and could take pressure off of the Jordanian
system. At this stage, with numbers much lower, transitioning
to the mainstream health system makes equal sense.

personnel and their mutual grantees and contractors
could help ensure continuing consultation between
refugee specific and mainstream service providers. The
dual approach taken by the two agencies—the IRD
program focused on the refugees and the Abt USAID
program focused on the Jordanian health system—
makes sense but it could be better coordinated so that
the findings of each feeds into subsequent changes and
developments in the other. The IRD project has important
information about the barriers that refugees find in
gaining access to care, whereas the Abt program is more
knowledgeable about the strengths and weaknesses
of the mainstream health care system. Pooling such
knowledge in consultation with the respective donor
agencies would help to ensure a more coherent
approach to health mainstreaming. Respondents from
Abt as well as refugee implementing partners expressed
interest in meeting to discuss common interests.

Some improvements that could be made in Jordan,
and more generally in addressing the mainstreaming
of refugees into health services worldwide, include:

Government of Jordan
•

Maintain emphasis on mainstreaming of refugees into the
local health care system. Jordan is to be complimented
for its foresight in working with UNHCR and other actors
in helping refugees to access its community health
centers and hospitals. Jordan’s generosity in this regard
is a model to be emulated by other host countries.

•

U.S. Government
•

Strengthen coordination between PRM and USAID
teams at the country level. Regular meetings of embassy

12

Address refugee funding cycles that are too short to
accomplish effective mainstreaming. A mainstreaming
approach requires sustained attention to addressing
the barriers that impede access to care in mainstream
agencies and to addressing any adverse impacts on
those services in incorporating new populations.
Facilities may need to be expanded, staff hired with
appropriate language and clinical skills, new services

Journal Articles

The prospect of formal local integration is also unlikely.
Ultimately, Jordan will determine what level of rights,
particularly to employment and continued residence,
will be afforded to refugees. With high unemployment,
particularly among educated Jordanian youth, complete
access for refugees to the job market is seen as unlikely
by stakeholders and refugees alike. Government officials
expressed concerns about what they consider to be the
burden of hosting large numbers of refugees, indicating that
without continued international support, the government
would be unable to bear the costs of providing health and
education services. In referring to the Iraqis as “guests”
of the country, the Jordanian government reflects its

reluctance to see these refugees—as distinct from the larger
number of Palestinian refugees—as “locally integrated.”

Journal Articles

developed to address refugee-specific problems,
such as post-traumatic stress, and new data systems
developed to capture information about the new clients.
•

Reduce funding-related inequities among refugees
in access to health care. Programs that are linked to
a specific refugee group, such as the Iraqi refugee
services that have been funded in Jordan, hold the risk
of favoring one group of refugees over others who, on a
needs basis, may have equal or greater call on services.
This situation is particularly problematic when the
host community may harbor biases in favor of certain
groups of refugees on the basis of shared religion or
ethnicity, as is the case in Jordan towards Iraqis and
Palestinians as compared to sub-Saharan Africans.
Donors should be especially careful to monitor refugee
programs to ensure that all refugees receive equal
access to basic health care, as per the UNHCR guidelines.

•

Consult regularly with refugees as well as stakeholders
to identify needs and independently assess the
effectiveness of U.S.-funded programs. The study
team found that visits to refugee service agencies
to observe implementation of programs proved
to be highly useful in identifying issues to be
addressed. Working through community based
organizations with good relations with the refugee
community is another way to establish contacts with
refugees to hear their views on service provision.

•

Continue to support the fund now administered
by UNHCR and WHO through the ECC. This fund is
comparable to the one available to Jordanian citizens
through the Royal Court and ensures that refugees are
not discriminated against in their need for secondary
and tertiary care, as compared to citizens of Jordan.

•

Address delays in resettlement processing and provide
refugees with more information on their cases. Many
refugees who have applied for resettlement are awaiting
final security clearance. There is little information
available to them about the state of their case. The
delays and lack of transparency place an especially high
burden on those with serious medical problems and
their families. If there is need for medical resettlement,
and delays in processing will impede timely arrival in the
United States, alternatives should be examined, including
the use of remote technology or deployment of military
teams that may be able to do needed surgery on site.

A) actions to be taken to build mainstream capacity
and educate refugees and stakeholders about available
services (a combination of the Abt Associates and IRD
programs may be appropriate models for addressing
mainstreaming in other refugee crises); and, B) refugeespecific services that will be needed for at least a transition
period because mainstream services are not available,
will be overburdened or are inappropriate to the needs
of refugees. Annually, assessments should measure
the extent to which refugees use the mainstream
health care system, identifying actual barriers as well as
perceptions on the part of both the mainstream system
and the refugees that discourage use of these services.
Such assessments should seek to identify ways to
continue to enhance the capacity of the health services
and to reduce barriers that refugees may experience in
gaining access to the mainstream services. To the extent
possible, such assessments should be carried out by a
team that combines expertise on the local health care
system and the health care needs of refugees in order to
ensure that the assessment’s recommendations address
mainstreaming from both perspectives—that of the
mainstream health care system and that of the refugees.
•

Maintain refugee-specific health services to fill gaps
in the mainstream system, particularly psycho-social
programs, mental health counseling and other services
needed because of the refugee experience, particularly
among children. In many cases, mainstream health
services will not be able to develop and implement
programs quickly enough to address the health care
needs of newly arriving refugees. In such cases, refugeespecific programs implemented by agencies with
extensive experience in responding to refugee health care
needs may be needed—at least for a transitional period.

•

Negotiate with the Government of Iraq (GoI) to establish
a fund for secondary and tertiary care for Iraqi refugees
in order to reduce some of the impact on both the
mainstream system and individual refugees. The GoI
already provides support for its citizens who travel to
Jordan for tertiary health care. Extending this support to
Iraqi refugees who are unable or unwilling to return to
Iraq at the present time would be within Iraq’s financial
capacity and an extension of the responsibility it already
has taken on for its citizens. Such a fund may also help
restore ties between the government and the Iraqi
refugees by demonstrating the government’s concerns
for its population, regardless of where they are located.
In turn, this type of program might help encourage
repatriation by demonstrating the legitimacy of
the Iraqi government in the eyes of the refugees.

•

Reassess the 2009 conclusion that appropriate health
insurance coverage for refugees in Jordan was not
feasible. In 2009, UNHCR identified several barriers
to health insurance: A) the health insurance scheme
would exclude many categories of people, including
non-Iraqi refugees, those aged 65 years and over,
newborns with congenital and hereditary diseases
(such as Thalassemia), people with sexually transmitted
infections, and those with neurological diseases and
mental illness; B) it would cost 26 per cent more to
provide health services using the health insurance
scheme than with its implementing service providers;

UNHCR
•

Assess systematically and continually the capacity of
the mainstream system, the needs of the refugees, and
the likelihood that these needs can and will be met
by the mainstream system. The lessons of Jordan are
illustrative of the approach that should be taken more
broadly in urban refugee contexts. As early as possible
in a refugee crisis, the capacity of the mainstream
system should be assessed to determine whether it is
capable of delivering health care services to refugees
without adversely affecting the health of either their
existing patients or the arriving refugees. Based on the
initial assessment, UNHCR, with the support of donors
and participation of implementing partners, should
prepare a specific mainstreaming plan that identifies:

13

C) UNHCR would require increased administrative and
technical capacities to oversee the private insurance
scheme; and, D) UNHCR would require a stable
budget allocation rather than incremental increases of
budget targets over the year in order to best plan for
the numbers of refugees to be covered by the annual
insurance scheme (UNHCR 2012).6 These are serious
impediments but the situation has changed sufficiently
in the past three years (particularly since the numbers
of refugees have declined) to merit reconsideration.
•

Refugee Service Providers
•

Raise awareness of mainstream health services and
eligibility of refugees through outreach to the refugee
communities. Discussion groups with refugees
demonstrated that they are aware of mainstream
programs but have many misconceptions about the

A final word on Syrians and Iraqis in Syria:33 as of the time
of the January site visit, the numbers of Syrian refugees and
Iraqi refugees who had left Syria were quite low. At the time
of our trip, it was estimated that there was an approximate
total of 6,000 Syrians in Jordan and 2,500 UNHCR-registered
Syrians already in the North.7 Subsequently, the numbers
have increased substantially: to 140,000 in August 2012. An
unknown number of Iraqis had also left Syria; generally they
transited back through Iraq to reach Jordan due to restrictions
on entry for Iraqis on the Syrian border. Our research team
interviewed some of these refugees. It appeared that the
Syrians are less well educated and poorer than many of the
Iraqi refugees. In January, they were primarily in rural areas of
Jordan. Not much contingency planning appeared to have
taken place to determine how to respond if the numbers
began to increase dramatically or, for that matter, if things
deteriorate in Iraq and new exodus occurs. Camp areas at the
time of our visit had been demarcated and leveled, but most
stakeholders expressed great reservations about establishing
camps for the Syrians. One camp has since been opened.
The sustainability of programs is also of concern, particularly
if the resources are spread between the existing caseload
and new arrivals. Some of program changes for the existing
caseload have been predicated based on lower numbers
than those in actual need of services. Whether this will be true
in future is an open question, as is the continued patience of
the Jordan government in hosting thousands of refugees. As
such, it is important for the United States and the broader
international community to provide continued support
to the Government of Jordan in recognition of its valued
contributions to the protection of refugees. More specifically,
addressing the issue of tertiary care, either through Iraq
government funds or international support, would help
reassure the Jordanian government that they will not be left
with this major fiscal burden while providing essential services
to some of the most vulnerable refugees in the country.

More information on the situation of Syrians in Jordan at the time of writing in August 2012 can be found in the main report on urban
refugees in Amman.
7
Estimates as of the writing of this report in May 2012 are considerably higher.
6

14

Journal Articles

Evaluate the effectiveness of the WHO implemented
project in addressing the secondary and tertiary
needs of refugees to determine if the model would
work in other urban refugee contexts. Refugees in
many urban areas will include, as is the case in Jordan,
individuals with chronic diseases, such as diabetes
and hypertension, and acute needs, such as heart
attacks and cancer. Especially in developing countries,
it is unlikely that the mainstream services will have the
capacity to absorb high medical costs associated with
these conditions. Also, especially in situations in which
refugees are ineligible to work for wage employment or,
if eligible, unlikely to find good paying and sustainable
jobs, the refugees themselves will not be able to pay
the expenses associated with such care or with health
insurance, to the extent it is available. The establishment
of a committee to determine the medical necessity of
medical treatment in relationship to their costs makes
sense in such cases. Decisions on care should be geared to
the extent possible to the standards used in determining
eligibility of host country nationals to the same types
of treatment. A separate fund operated by UNHCR, in
consultation with or delegated to WHO, would then
provide the funding needed to ensure that the refugees
are not treated any differently than host country
nationals when chronic and tertiary care is required.

quality and availability of health services. Pamphlets
explaining the nature of the Jordanian system
are useful but insufficient for overcoming these
misconceptions. Outreach by trusted agencies that
already have connections to the refugees will help
overcome barriers to utilization while identifying real
problems in utilization that need to be overcome.